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Anticoagulant-related bleeding in older persons with atrial fibrillation: physicians' fears often unfounded
Malcolm Man-Son-Hing1, Andreas Laupacis
1Clinical Epidemiology Program, Ottawa Health Research Institute, Geriatric Assessment Unit, Ottawa Hospital, and Division of Geriatric Medicine, University of Ottawa, Ontario, Canada. mhing@ottawhospital.on.ca
Insights
Physicians often overestimate bleeding risks, leading to underuse of anticoagulant therapy for stroke prevention in older adults with atrial fibrillation. Focus should be on stroke risk, not exaggerated bleeding concerns.
Area of Science:
- Geriatrics
- Cardiology
- Pharmacology
Background:
- Anticoagulant therapy (e.g., warfarin sodium) is underutilized for stroke prophylaxis in elderly atrial fibrillation patients.
- Physicians' concerns about bleeding risks due to factors like hypertension and falls often deter prescribing anticoagulants.
Purpose of the Study:
- To evaluate if bleeding risk factors impact anticoagulant-related hemorrhage in older atrial fibrillation patients.
- To propose an approach for using anticoagulants in this population despite risk factors.
Main Methods:
- A systematic literature search of MEDLINE was conducted.
- The search covered publications from January 1966 to March 2002.
Main Results:
- Many perceived barriers to anticoagulation, such as prior gastrointestinal bleeding or falls, may not significantly affect stroke prophylaxis choices.
- Evidence on factors like alcoholism or noncompliance is conflicting, but they warrant consideration in clinical decisions.
Conclusions:
- Physicians' fears of bleeding complications with anticoagulants in older atrial fibrillation patients are frequently exaggerated.
- Accurate stroke risk assessment is paramount; bleeding risk is a secondary concern for most patients.
Background:
Many studies have documented the underuse of anticoagulant (ie, warfarin sodium) therapy as stroke prophylaxis in older persons with atrial fibrillation. Failure to prescribe anticoagulant agents to these patients is often due to physicians' perceiving the risk of major bleeding as unacceptably high because of the presence of such clinical risk factors as hypertension, falls, a history of gastrointestinal tract bleeding, and lack of assurance about compliance.
Objectives:
To critically appraise whether the presence of additional clinical factors that increase the risk of bleeding affects the chance of anticoagulant-related hemorrhage, and to develop an approach to the use of anticoagulant agents in older patients with atrial fibrillation who have any of these factors.
Methods:
Systematic MEDLINE literature search from January 1966 to March 2002.
Results:
Many of the factors that are purported to be barriers to anticoagulant therapy in older persons with atrial fibrillation probably should not influence the choice of stroke prophylaxis in these patients. These include previous episodes of upper gastrointestinal tract bleeding, predisposition to falling, and old age in itself. For some other factors, such as alcoholism, participation in activities that predispose to trauma, the presence of a bleeding diathesis or thrombocytopenia, and noncompliance with monitoring, there is little or conflicting evidence about their effect on anticoagulant-related bleeding. However, they should be considered in the clinical decision-making process.
Conclusions:
For many older patients with atrial fibrillation, physicians' fears of the risk of bleeding in association with anticoagulant therapy are often exaggerated and unfounded. Therefore, the salient issue in selecting older patients with atrial fibrillation for anticoagulation is accurately estimating their stroke risk, with bleeding risk during anticoagulation being a lesser issue, relevant to only a few patients.